1. Ressler, Alexis B. MEd, RN


A student reckons with the limits of compassion.


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On our first night together, I bathed her, gently working the washcloth around the labyrinth of tubing. Charlotte, 15 years old, was back in the ICU after just a month at home, this time for pneumonia. Her previous stay, because of Stevens-Johnson syndrome triggered by chemotherapy, had lasted for five months. The circumference of her calves was smaller than that of my wrists. Her feet resisted my attempts to flex them, and I struggled to put on her podus boots. I washed her bald head and cleaned the sores on her lips. She mouthed to me, silent syllables around her endotracheal tube: "You have pretty eyes."


I released Charlotte's wrist restraints and washed her hands, which seemed conspicuously healthy compared with the rest of her body. Her fingers were smooth and slender, with long, perfectly manicured fingernails painted lipstick red.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Pat Kinsella

She mouthed something else. I told her to keep trying, and finally made out the words, "I want to go to school." Then she dozed off, sleep a brief respite from the pain and discomfort of intubation. On my way out of her room, I noticed the magazine photos of Brad Pitt, Johnny Depp, and Matt Damon taped to the wall across from her bed.


The next night, she mouthed, "I want my bath soon." I was getting better at reading Charlotte's lips. As I washed her, I quietly hummed to the soft music on the radio. She seemed to find music soothing (once when I'd looked in on her I'd seen her mouthing words to songs). Soon after I'd finished, she had a coughing spell and became agitated. Her mouth was moving too quickly for me to make out her words. She tugged at the restraints with her wrists, and I finally understood that she was saying, "Take these off me!!"


As I explained that they were there for her own safety, Charlotte stared at me in anger. I found myself apologizing over and over. Finally she looked away, refusing to meet my eyes again that night.


The nurses in the ICU felt great affection for Charlotte and were disheartened by her setback; they didn't want to see her stripped of consciousness again, unable to interact with family members, so they'd recently decided to attempt to use less sedation. (She was receiving large iv doses of hydromorphone as well as phenobarbital.) When the day shift nurse arrived that morning I told her how difficult it had been for me to deny Charlotte's wishes. I don't know whether this affected her decision, but when I came back that night for the final night of my pediatric ICU rotation, I learned that Charlotte had spent the day without restraints. She was beaming, elated at her freedom. Her family had made a rare visit, finally leaving just as I arrived, and she'd spent part of the day in a chair.


The day shift nurse seemed confident that Charlotte could be trusted overnight without restraints, but patients can be different at night in the ICU and I was nervous. She had a long period of coughing and restlessness between 7 pm and 8 pm and had to be suctioned repeatedly. Finally her nurse sedated her and she went to sleep.


By 2 am she was awake, her red fingernails exploring the various tubes that entered and exited her body. I told her it was crucial that she not pull on anything and gave her a pillow to hold onto instead. At some point I turned away from her for just a second. When I turned back around she had both hands on the endotracheal tube and was pulling hard. "Let go!!" I shouted. As several people came running into her room, I tried to pry her hands off the tubing but was surprised by her strength. A voice in the crowd behind me said, "That's it. We have to put the restraints back on."


She let go of the tube, and her eyes filled with tears as I held her wrists. She mouthed over and over, "I got confused." She begged me to leave the restraints off. The alarm on the mechanical ventilator began to beep. As the respiratory therapist checked the equipment, she mouthed to him, "Can you take me home?"


A nurse on the other side of the bed restrained her left hand as I held her right. At first she resisted, but then gave up, too weak to fight. Tears rolled down her cheeks. I let her hand go free for a second so she could wipe her tears away; then she let me put her hand into the restraint. I bent over her, concentrating on the task, avoiding her gaze.


By 4 am Charlotte was finally asleep. In just a few hours my clinical rotation would be over. I stood in the doorway, watching her. A voice behind me said quietly, "The ICU is a tough place to work." I nodded but didn't turn around. While I knew the nurses would go on doing whatever they could to reduce the need for Charlotte to wear restraints, I resisted the dawning knowledge that it might not be enough.